Transoperative pain management: A framework

Pain can be protective, but through the stress response it also may make significant contributions to patient morbidity and even mortality. A recent study in humans, for example, revealed that in people undergoing routine ambulatory surgery, persistent pain will be experienced by 10 percent to 50 percent of patients, and the chronic pain will be severe in 2 percent to 10 percent of these individuals.1

Mark E. Epstein, DVM, Dipl. ABVP, AAPM, CVPP

Thus, the priority clinicians should place on pain management in the acute and perioperative setting is not just to minimize discomfort but to prevent, insofar as possible, the potential for any chronic pain syndrome.

A foundation of effective pain management is the use of multiple modalities, which allows for intervention at several different places along the nociceptive pathway. This can not only improve patient comfort but minimize the need for high or protracted doses of any one particular drug.

For example, it is well-established in human medicine, that using adjunct medications will minimize the use of patient-controlled analgesia (opioids), resulting in a decreased incidence of adverse effects such as nausea and constipation and an earlier exit from the hospital.2-5 And the U.S. military concluded in a recent landmark analysis, "Multimodal therapy encompasses a wide range of procedures and medications, including regional analgesia with continuous epidural or peripheral nerve block infusions, judicious opioids, ... anti-inflammatory agents, anticonvulsants, ketamine, [alpha-2 agonists], ... antidepressants, and anxiolytics as options to treat or modulate pain at various sites of action."6 So, with a more aggressive, acute pain management strategy, the military decreased acute and chronic pain conditions, which may have application in the civilian sector, too.

The need for a framework

The good news is that veterinary clinicians have a vast array of possible pharmacologic interventions. The bad news: Clinicians are faced with a vast array of possible pharmacologic interventions. That is, of all the possibilities, what should any one patient receive? At what dose, or in what combination? How often and for how long? And many clinicians remain uncertain or uncomfortable with polypharmacy, concerned with matters such as possible drug interactions, adverse effects, cost and managing scheduled drugs.7

Proposed here is a framework of transoperative pain management—preceding the incision, through the surgical period itself and into the recovery period. By definition, it cannot be a one-size-fits-all strategy, because there's no such thing. Rather, it's a scaffold upon which clinicians can structure the pain management needs of most every patient.

While there is no metric to evaluate the quality of pain management across veterinary practices, previous studies have demonstrated a tendency toward the underuse of strong opioids and locoregional anesthesia.8 Also, while use of nonsteroidal anti-inflammatory drugs (NSAIDs) remains widespread and fairly ubiquitous, over-reliance on this class of drugs alone likely would not only undermanage some (perhaps many) patients for their pain, but could increase the possibility of NSAID-induced adverse effects. In contradistinction, using a combination of antianxiety medications, strong opioids and locoregional anesthesia in addition to NSAIDs would elevate a practice's pain management strategies to the top tier.